Provider Demographics
NPI:1215020797
Name:TAILLEUR, DANIEL (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:TAILLEUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 639
Mailing Address - Street 2:
Mailing Address - City:LA JARA
Mailing Address - State:CO
Mailing Address - Zip Code:81140-0639
Mailing Address - Country:US
Mailing Address - Phone:719-274-6000
Mailing Address - Fax:719-274-6038
Practice Address - Street 1:19021 US HIGHWAY 285
Practice Address - Street 2:
Practice Address - City:LA JARA
Practice Address - State:CO
Practice Address - Zip Code:81140
Practice Address - Country:US
Practice Address - Phone:719-274-6000
Practice Address - Fax:719-274-6038
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO50386207Q00000X
MT11161208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT11161OtherSTATE LIC NUMBER
CO50386OtherSTATE LICENSE
I63162Medicare UPIN